Illustration of human hand with a tiny person standing on the palm.

Models of dysfunctional posture and structure have evolved because they make sense within the dominant biomedical and biomechanical framework that is most pervasive in musculoskeletal medicine.

In any mechanical system, if the coordinated moving parts are not correctly aligned, the moving system is not working most efficiently. This inefficiency may eventually lead to breakdown. That concept makes sense and has been applied extensively in most disciplines that address musculoskeletal pain complaints.

However, the human body is much more complicated than a simple machine.

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Research has shown that there can be a weak correlation between structural or postural challenges and corresponding pain complaints. For example, just because someone has forward head posture doesn’t mean they are destined to have back or neck pain. This weak correlation has become a primary argument for those who critique postural or mechanical treatment approaches. However, this critique can also be misleading.

A weak correlation means you can’t assume there is a direct cause-effect relationship. Just because a postural or structural challenge exists, doesn’t mean it is the cause of someone’s pain.

Yet, that doesn’t mean the postural problem is irrelevant and you should ignore it. There are numerous instances when posture and structure definitely play a role in a client’s complaint. So, how do we know when a particular postural or structural problem is relevant?

The Role of Assessment

There are important guidelines that can help determine if a postural or structural issue is a contributing factor. For decades I have been a strong advocate of using comprehensive assessment with our clients, with the degree of assessment depending on the complexity of the issue.

Assessment helps the therapist better understand the context of postural or structural problems, their physiological impact, and how relevant they are for the client’s current complaint.

The relevance of postural challenges depends on each client’s unique situation. Whether or not a particular postural problem might be pertinent is highly dependent on what factors might be exaggerating the mechanical loads from that postural challenge.

For example, a client might have lived their entire life with a lateral pelvic tilt and a leg length discrepancy and never had any problem. If you happen to identify those postural or structural challenges during your treatment session, it may be erroneous to introduce the idea that this is something the client needs to fix or change, because it has not caused any significant problem to begin with.

On the other hand, if that same client just started a new running regimen and is now having sacroiliac and low-back pain, the relevance of the postural challenge is very worthy of investigation. The pelvic tilt and leg length discrepancy exaggerates the constant and repetitive load on this region from the new running routine.

In this article, we’ll look at a couple of common postural and structural disorders and explore how we can best approach them. We take into consideration current biomechanical research, but also consider the limitations of what we still have yet to learn.

Posture and Pain

Let’s look at two common postures that are often identified as contributing to client pain complaints. The first example looks at a pain complaint that cannot really be addressed via the mechanical model because changing structure is very unlikely. Adaptation is key here. In the second example, we actually can use some of the mechanical model idea in order to address pain.

1. Tilted pelvis.The pelvis is not a highly mobile region, but it certainly has garnered its fair share of attention as a postural challenge. The literature in our field and other manual therapy fields is rife with references to anterior, posterior, and lateral pelvic tilts, upslips, torsions, and other structural and postural misalignments of the pelvic region. Unfortunately, the biomechanical literature does not support many of the assessment or treatment strategies to address these pelvic anomalies.

Interrater reliability is a measure of how accurate an assessment procedure is when multiple people perform it. Ideally, if 10 different practitioners evaluate the same client when assessing for a pelvic alignment problem, they should all come up with the same determination.

Unfortunately, a good number of the sacroiliac joint and pelvic position assessment tests have poor interrater reliability. Does that mean these conditions don’t exist and are not important? Not necessarily.

Numerous factors may lead to sacroiliac joint pain. Pelvic alignment is undoubtedly one of those factors. Yet, we do know accurately measuring position or alignment is difficult. Biomechanical research has also suggested that it is difficult to change structure and position of the pelvis through soft-tissue treatment interventions.

Yet, we also know that soft-tissue treatment of pain conditions in this region are often very effective in restoring pain-free movement. So, what is occurring here in these conditions?

Accurate assessment may help us pinpoint what seems to be the primary culprit in some of these pain complaints. By selectively stressing various tissues in this region during the assessment, we may be able to determine if pain is primarily originating from irritation of sacroiliac ligaments, myofascial trigger points, entrapment of cluneal nerves, irritation of sacroiliac joint surfaces, tightness in distal lumbosacral muscles, or other factors. Specific treatments can target the primary tissues that appear to be driving the pain complaint.

In this instance, massage isn’t being used with the primary intention of changing a pelvic alignment — which is quite difficult. Instead we are focusing attention on what is called the nociceptive driver, the primary tissue responsible for generating the neurological signals that are producing pain.

Nociception is the chemical, thermal or mechanical sensory signal that the brain interprets as pain. Massage is an excellent strategy for reducing excess nociceptive input to reduce pain.

In this instance, our treatment goal is not necessarily to change a pelvic alignment position, but instead to help manage nociception. The eventual end goal is likely to be reduced pain even if the postural alignment challenge still exists.

Yet, just as described above, it will be crucial to work with the client to help reduce mechanical factors that put increased mechanical load on the region that will further drive tissue irritation or injury and increase nociceptive input.

In a case like this it is best to advise the client on alterations in movement or postures that they know contribute to their pain. Keeping a journal is an excellent way for a client to help correlate their pain to their daily activities.

2. Forward head posture. This is probably one of the most common postural challenges in our culture. The rise of occupations with sedentary body positions and focus on computer, mobile phone and tablet screens appears to exaggerate this posture even further.

Other factors may also play an essential role in developing forward head posture. For example, I played tenor saxophone in the school band when growing up, and as a result I developed a significant forward head posture from spending hours each day with the weight of the saxophone hanging on my neck.

Today, I frequently have low-back pain, and after extensive evaluation, I can correlate that pain with my forward head posture in a particular way. There are many days when this posture doesn’t bother me at all. However, if I stand in relatively static positions for long periods with the forward head posture, such as in the classroom when teaching or in the kitchen while cooking, my low back will hurt as a result.

Ironically, it rarely bothers me when I sit at my desk all day working on the computer. This is because I have found a chair-and-desk position that decreases the mechanical load even when I am at the computer for long hours at a stretch.

Constant movement, I’ve learned, is the best antidote to prevent my back pain. I have often tried to address the problem with massage alone, only to have it recur at the next instance of sedentary standing. Massage is helpful to address the symptoms of back pain and the resultant muscle tightness, but movement and changes in how I stand or hold my body are the essential keys to prevent the problem in the first place.

This is an example where a postural/structural challenge is relevant to the existing pain complaint. However, more extensive evaluation and assessment were necessary to identify when and how this problem was manifesting.

It is tempting to look at the postural challenge primarily from a massage perspective and focus attention on the short-and-tight muscles on the anterior side with the idea that merely working these will change the postural condition; however, our more current understanding of motor learning and neuromuscular patterns reminds us it is not that simple.

Movement and continual reinforcement of new motor patterns are necessary to alter habitual postures and motor patterns that we have learned and reinforced over time.

Important Treatment Considerations

What is most helpful is if we approach each of these problems in a constructive way with our clients and remember that we play two separate roles in each therapeutic encounter. We are a practitioner who performs soft-tissue manipulation, and we are an educator who helps them learn more about their body and how to live a more pain-free life.

Here are some essential guidelines to remember as we look at various postural and structural problems with our clients:

• Don’t pathologize every postural challenge. Not everything needs to be corrected. The body is highly adaptable to asymmetry.

• Use language and descriptions that are more positively oriented, such as letting the client know that you think massage is likely to help them move more freely and with less pain, regardless of their postural or structural challenge.

• Steer clear of narratives that focus on postural or structural challenges in a negative light, such as “Look at that overpronation in your foot. It’s no wonder your knee hurts.”

• Remember that each person is an individual, and we don’t have to get everyone to fit into some ideal postural alignment — such as having anatomical landmarks perfectly lined up with a plumb line, for example.

• When looking at any postural condition, consider the context of how that person is using their body and any other biomechanical factors that may either offset or exaggerate the postural challenge.

Enhance Positive Responses

Postural challenges involve a complex interplay of biomechanical, biological, psychological and social factors. Merely attempting to address a soft tissue pain complaint only from the mechanical lens of changing structure or posture might address only a limited part of the problem. When we move our attention away from posture and structure purely as a mechanical distortion that needs to be fixed, it lets us view each client more as a whole person.

Massage is very helpful in reducing prolonged tightness in muscles and helping reduce pain in numerous conditions; however, it’s less clear that massage can actually change posture in many instances. Postural change seems to be strongly driven by motor learning and repeated neuromuscular patterns.

Despite the very best massage treatment in the world, a person can easily slip back into their stooped postural pattern on the way home. Some pain complaints in which a posture is a factor are better addressed after assessing the client more holistically, and making subtle changes in movement patterns and treating for pain reduction.

In other cases, focusing more attention on helping to enhance positive responses through the neurological system may be more important than potential changes we might have thought we were making by changing posture or movement patterns. This shift in perspective might help emphasize some of the most powerful aspects of what happens in the treatment room: namely, neurological responses and the power of the client-therapist relationship.

About the Author:

Whitney Lowe, LMT, directs the Academy of Clinical Massage. He teaches continuing education in advanced clinical massage through the academy, and offers an online training program in orthopedic massage. He is a regular contributor to MASSAGE Magazine. His articles include “Clinical Reasoning as a Component of Orthopedic Massage.” Lowe is also a MASSAGE Magazine All-Star.